| NPI | 1740630391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 4025) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IA 083164) |
| Enumeration Date | 2016-06-14 |
| Last Update Date | 2021-01-19 |