| NPI | 1841586500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 2840-023) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IA 002201) |
| Enumeration Date | 2011-06-21 |
| Last Update Date | 2012-09-18 |