| NPI | 1710954805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03475) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: MN 9287) | |
| Enumeration Date | 2006-03-07 |
| Last Update Date | 2021-08-20 |