| NPI | 1396173746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11487) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: IA R-12261) | |
| Enumeration Date | 2013-10-23 |
| Last Update Date | 2022-11-09 |