| NPI | 1710382601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 346123) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WI 346123) |
| Enumeration Date | 2014-11-04 |
| Last Update Date | 2015-10-27 |