NPI | 1679114862 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13342) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI MC5789435) |
363AM0700X Physician Assistant, Medical (Licence: NC 0010-09426) | |
Enumeration Date | 2019-09-30 |
Last Update Date | 2022-11-28 |