| NPI | 1003836701 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MN 9155) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 500023) |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2007-07-08 |