| NPI | 1164603783 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ND PAC0567) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: ND PAC0567) |
| 363AS0400X Physician Assistant Surgical (Licence: MN 10359) | |
| Enumeration Date | 2007-11-26 |
| Last Update Date | 2023-05-15 |