| NPI | 1609142066 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 208800000X Urology (Licence: MN 69687) | 
| Additional Taxonomies | 208800000X Urology (Licence: MN 30665) | 
| 363AM0700X Physician Assistant, Medical (Licence: MO 2012005136) | |
| 363AS0400X Physician Assistant, Surgical (Licence: MO 2012005136) | |
| 208800000X Urology (Licence: WI 85915-20) | |
| Enumeration Date | 2012-03-29 | 
| Last Update Date | 2025-09-15 |