| NPI | 1578191003 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ND PAC0966) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085007768) |
| Enumeration Date | 2020-03-30 |
| Last Update Date | 2026-01-22 |