| NPI | 1811991359 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 3305) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 10410) |
| 363AS0400X Physician Assistant, Surgical (Licence: WI 1692) | |
| Enumeration Date | 2005-06-13 |
| Last Update Date | 2018-02-13 |