| NPI | 1952563223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 2531) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 001910) |
| Enumeration Date | 2008-06-27 |
| Last Update Date | 2014-01-10 |