| NPI | 1760522213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2418-023) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: WI 3182-125) |
| Enumeration Date | 2007-02-07 |
| Last Update Date | 2009-08-04 |