| NPI | 1548669955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 3442) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MN 11732) |
| 363AS0400X Physician Assistant, Surgical (Licence: WI 3442-23) | |
| 363A00000X Physician Assistant (Licence: MN 11732) | |
| Enumeration Date | 2014-08-21 |
| Last Update Date | 2026-01-21 |