| NPI | 1790823045 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 1865) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 1865-23) |
| Enumeration Date | 2007-02-01 |
| Last Update Date | 2019-01-18 |