| NPI | 1053684985 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ND PAC1009) |
| Additional Taxonomies | 1710I1003X Military Health Care Provider, Independent Duty Medical Technicians |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2012-02-23 |
| Last Update Date | 2023-08-11 |