| NPI | 1760455083 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 001920) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 9796) |
| Enumeration Date | 2006-02-08 |
| Last Update Date | 2022-06-07 |