| NPI | 1699757880 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2909-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 001734) |
| 363A00000X Physician Assistant (Licence: VT 055.0030930) | |
| 363AS0400X Physician Assistant, Surgical (Licence: IL 085002558) | |
| 363A00000X Physician Assistant (Licence: IL 085002558) | |
| Enumeration Date | 2005-11-15 |
| Last Update Date | 2023-04-19 |