| NPI | 1760482095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12351) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 1064-023) |
| Enumeration Date | 2005-07-28 |
| Last Update Date | 2023-01-10 |