| NPI | 1194778068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ND PAC0014) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 8880) |
| 363AM0700X Physician Assistant Medical (Licence: ND PAC0014) | |
| 363AM0700X Physician Assistant Medical (Licence: MN 8880) | |
| 363AS0400X Physician Assistant Surgical (Licence: MN 8880) | |
| 363AS0400X Physician Assistant Surgical (Licence: ND PAC0014) | |
| Enumeration Date | 2006-05-19 |
| Last Update Date | 2022-06-15 |