| NPI | 1922096379 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AR PA970) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 10025) |
| Enumeration Date | 2005-10-10 |
| Last Update Date | 2021-04-05 |