| NPI | 1922130137 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2671) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AM0700X Physician Assistant, Medical (Licence: ME PA001096) | |
| Enumeration Date | 2007-03-12 |
| Last Update Date | 2010-11-18 |