| NPI | 1629051347 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 971) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 9180) |
| Enumeration Date | 2005-11-28 |
| Last Update Date | 2022-03-23 |