| NPI | 1720393689 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 2573023) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 64970) |
| Enumeration Date | 2010-08-16 |
| Last Update Date | 2024-11-01 |