| NPI | 1639275605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10395) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA04471) |
| Enumeration Date | 2006-09-16 |
| Last Update Date | 2017-04-06 |