| NPI | 1639148604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 1695) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110008918) |
| 363A00000X Physician Assistant (Licence: TX PA07135) | |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2022-12-02 |