| NPI | 1154659662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2523) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 12087) |
| Enumeration Date | 2009-11-20 |
| Last Update Date | 2023-12-19 |