| NPI | 1407814551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ND 103160) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 103160) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 103160) | |
| Enumeration Date | 2006-05-01 |
| Last Update Date | 2024-08-01 |