| NPI | 1942039482 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 8146-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085011036) |
| 363A00000X Physician Assistant (Licence: MI 5601012921) | |
| 363A00000X Physician Assistant (Licence: UT 14195522-1206) | |
| Enumeration Date | 2024-08-01 |
| Last Update Date | 2025-01-28 |