| NPI | 1912269184 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 5580) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: WI 1867-19) |
| Enumeration Date | 2012-06-13 |
| Last Update Date | 2021-11-05 |