| NPI | 1154439487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MN 13259) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 1252) |
| Enumeration Date | 2006-08-27 |
| Last Update Date | 2019-12-13 |