| NPI | 1497059406 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 56687) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1521) |
| 363A00000X Physician Assistant (Licence: MN 10880) | |
| Enumeration Date | 2011-01-05 |
| Last Update Date | 2020-03-24 |