| NPI | 1861020133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 5540) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IA 109777) |
| 363AM0700X Physician Assistant, Medical (Licence: MN 13797) | |
| Enumeration Date | 2020-03-31 |
| Last Update Date | 2021-11-24 |