| NPI | 1922200724 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ND PAC0720) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 1007) |
| 363A00000X Physician Assistant (Licence: MN 13003) | |
| Enumeration Date | 2007-06-04 |
| Last Update Date | 2022-05-10 |