| NPI | 1013576982 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WI 8061) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 13269) |
| Enumeration Date | 2019-06-13 |
| Last Update Date | 2025-06-16 |