| NPI | 1306166129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2619) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11539) |
| Enumeration Date | 2010-06-03 |
| Last Update Date | 2023-02-14 |