| NPI | 1013277052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 4474) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11149) |
| Enumeration Date | 2012-05-24 |
| Last Update Date | 2023-10-13 |