| NPI | 1497074454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 5365) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11108) |
| Enumeration Date | 2010-05-28 |
| Last Update Date | 2022-01-24 |