| NPI | 1205871266 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: SD 0762) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 9773) |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2016-04-13 |