| NPI | 1679219356 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 8700-023) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA63654) |
| Enumeration Date | 2022-05-06 |
| Last Update Date | 2026-01-19 |