| NPI | 1457330748 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 1348) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 9880) |
| Enumeration Date | 2006-01-13 |
| Last Update Date | 2023-12-15 |