| NPI | 1205512688 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ND PAC1013) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ND PA1013) |
| Enumeration Date | 2023-06-22 |
| Last Update Date | 2026-04-16 |