| NPI | 1336297043 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MN 9564) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VI 093) |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2026-06-11 |