| NPI | 1063535300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03547) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ND PAC1127) |
| Enumeration Date | 2007-04-10 |
| Last Update Date | 2024-11-20 |