| NPI | 1316404452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13036) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61039041) |
| 363A00000X Physician Assistant (Licence: WI 7054-23) | |
| Enumeration Date | 2019-02-25 |
| Last Update Date | 2022-10-12 |