| NPI | 1477198638 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 363AM0700X Physician Assistant, Medical (Licence: MN 13850) | |
| Enumeration Date | 2019-11-12 |
| Last Update Date | 2024-10-11 |