| NPI | 1306871751 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 0098) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 9273) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2008-05-08 |