| NPI | 1003811316 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: WI 978) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 9254) |
| Enumeration Date | 2005-06-15 |
| Last Update Date | 2023-12-06 |