| NPI | 1679805105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4316-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 10698) |
| Enumeration Date | 2010-02-09 |
| Last Update Date | 2023-03-07 |