| NPI | 1417258179 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14180) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9113808) |
| 363A00000X Physician Assistant (Licence: MI 5601006498) | |
| Enumeration Date | 2010-11-11 |
| Last Update Date | 2022-12-12 |