| NPI | 1679892434 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2525-023) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: WI 2525-023) |
| Enumeration Date | 2010-05-19 |
| Last Update Date | 2012-02-02 |