| NPI | 1376587386 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-02522) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 9659) |
| 363A00000X Physician Assistant (Licence: WI 1443) | |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2011-03-21 |