| NPI | 1902341571 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4154-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 085729) |
| Enumeration Date | 2017-01-05 |
| Last Update Date | 2022-07-21 |