| NPI | 1710429303 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12145) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 12218) |
| Enumeration Date | 2016-11-14 |
| Last Update Date | 2022-08-31 |