| NPI | 1861475006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 1050384) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 4330) |
| 363AM0700X Physician Assistant, Medical (Licence: IA 079199) | |
| 363AM0700X Physician Assistant, Medical (Licence: IL 085.005486) | |
| Enumeration Date | 2005-11-22 |
| Last Update Date | 2023-06-23 |