| NPI | 1508094343 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-09408) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MN 10972) |
| 363AM0700X Physician Assistant, Medical (Licence: WI 2446) | |
| Enumeration Date | 2009-07-01 |
| Last Update Date | 2021-04-01 |