| NPI | 1023658655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10343) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 13333) |
| Enumeration Date | 2020-01-11 |
| Last Update Date | 2021-06-14 |