| NPI | 1538786728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ND PAC0843) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ND 1174570) |
| 363AS0400X Physician Assistant, Surgical (Licence: ND 1174570) | |
| Enumeration Date | 2020-07-03 |
| Last Update Date | 2020-09-16 |