NPI | 1528517687 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13313) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 3905) |
363A00000X Physician Assistant (Licence: WI 3905-23) | |
Enumeration Date | 2016-09-29 |
Last Update Date | 2022-10-20 |