| NPI | 1669629549 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ND PAC0411) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11293) |
| 363A00000X Physician Assistant (Licence: AK 1981) | |
| Enumeration Date | 2008-08-22 |
| Last Update Date | 2015-03-02 |