| NPI | 1831569169 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 3682) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA057400) |
| Enumeration Date | 2015-09-29 |
| Last Update Date | 2023-07-17 |