| NPI | 1649588617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11617) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10001220A) |
| Enumeration Date | 2010-09-23 |
| Last Update Date | 2016-06-11 |