| NPI | 1750831632 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 1435) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 12214) |
| Enumeration Date | 2016-10-04 |
| Last Update Date | 2023-05-31 |