| NPI | 1679904247 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 3942) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL 9107562) |
| Enumeration Date | 2013-12-09 |
| Last Update Date | 2024-01-25 |