| NPI | 1760733133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4288-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1815) |
| Enumeration Date | 2012-09-26 |
| Last Update Date | 2023-02-09 |