| NPI | 1215290416 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ND PAC0482) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 102455) |
| Enumeration Date | 2012-06-21 |
| Last Update Date | 2022-01-03 |