| NPI | 1992753875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2120-023) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 10046) |
| 363AS0400X Physician Assistant, Surgical (Licence: WA PA60468333) | |
| Enumeration Date | 2006-05-04 |
| Last Update Date | 2016-03-01 |