| NPI | 1508349325 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 11243) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 12831) |
| Enumeration Date | 2018-09-07 |
| Last Update Date | 2023-02-02 |