| NPI | 1467435412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 4696) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 10970) |
| 363A00000X Physician Assistant (Licence: MN 2583) | |
| 363AM0700X Physician Assistant Medical (Licence: NC 0010-04315) | |
| 363AM0700X Physician Assistant Medical (Licence: AZ 2291) | |
| Enumeration Date | 2005-11-23 |
| Last Update Date | 2022-03-16 |