| NPI | 1881793206 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 1241) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 10686) |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2021-07-08 |