| NPI | 1184979676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 8014) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11169) |
| 363AM0700X Physician Assistant, Medical (Licence: MN 1766) | |
| Enumeration Date | 2012-07-20 |
| Last Update Date | 2024-11-14 |