| 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) | |
| Enumeration Date | 2012-03-29 |
| Last Update Date | 2021-07-15 |