| NPI | 1801295134 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4350) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 1117940) |
| 363A00000X Physician Assistant (Licence: IL 085005161) | |
| Enumeration Date | 2014-08-22 |
| Last Update Date | 2018-09-12 |