| NPI | 1013121565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12450) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.005279) |
| 363A00000X Physician Assistant (Licence: WA PA10005271) | |
| 363AS0400X Physician Assistant Surgical (Licence: OR PA01229) | |
| Enumeration Date | 2007-05-10 |
| Last Update Date | 2018-03-17 |