| NPI | 1568619682 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2366-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11324) |
| Enumeration Date | 2008-08-20 |
| Last Update Date | 2024-09-16 |