| NPI | 1841715679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4152-23) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2017-08-14 |
| Last Update Date | 2022-07-21 |