| 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 |