| NPI | 1740574516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10512) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 2005) |
| Enumeration Date | 2011-06-08 |
| Last Update Date | 2023-08-31 |