| NPI | 1225061450 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2658) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 9798) |
| Enumeration Date | 2006-07-09 |
| Last Update Date | 2022-11-17 |