| NPI | 1114234580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 3463) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1481) |
| 363A00000X Physician Assistant (Licence: MN 10847) | |
| Enumeration Date | 2010-09-08 |
| Last Update Date | 2015-02-25 |