| NPI | 1902807498 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MN 8883) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 1844-23) |
| Enumeration Date | 2005-08-09 |
| Last Update Date | 2018-04-16 |