| NPI | 1881953602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13273) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 5908-23) |
| 363A00000X Physician Assistant (Licence: TX PA09822) | |
| 363A00000X Physician Assistant (Licence: FL PA9114121) | |
| Enumeration Date | 2012-05-14 |
| Last Update Date | 2023-10-19 |