NPI | 1588270136 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13979) |
Additional Taxonomies | 363A00000X Physician Assistant |
363A00000X Physician Assistant (Licence: WI 22186) | |
Enumeration Date | 2020-09-18 |
Last Update Date | 2024-07-16 |