| NPI | 1033593025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ND PAC0603) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11875) |
| Enumeration Date | 2015-07-20 |
| Last Update Date | 2018-03-17 |