| NPI | 1548669955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MN 11732) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WI 3442-23) |
| Enumeration Date | 2014-08-21 |
| Last Update Date | 2015-06-30 |