| NPI | 1851048177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 7033) |
| Additional Taxonomies | 202K00000X (Licence: WI 7033-23) |
| Enumeration Date | 2022-03-07 |
| Last Update Date | 2025-01-08 |