| NPI | 1811217417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 7515) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WY 544) |
| 363A00000X Physician Assistant (Licence: MN 14748) | |
| 363AS0400X Physician Assistant, Surgical (Licence: WY 544) | |
| Enumeration Date | 2010-06-04 |
| Last Update Date | 2024-01-03 |