| NPI | 1700036944 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 095520) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 10500) |
| 363AM0700X Physician Assistant, Medical (Licence: MN 1200) | |
| Enumeration Date | 2008-09-24 |
| Last Update Date | 2020-09-22 |