| NPI | 1386964294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110003311) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MN 11088) |
| Enumeration Date | 2010-06-03 |
| Last Update Date | 2022-08-08 |