| NPI | 1770870933 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 3066) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IA 002224) |
| 363AM0700X Physician Assistant, Medical (Licence: MN 11917) | |
| Enumeration Date | 2011-07-07 |
| Last Update Date | 2017-12-13 |