| NPI | 1275556300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10228) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.002216) |
| Enumeration Date | 2006-07-26 |
| Last Update Date | 2020-10-09 |