| NPI | 1366826372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 1018) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 12284) |
| Enumeration Date | 2015-07-20 |
| Last Update Date | 2018-07-31 |