| NPI | 1922368794 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2931) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: MN 2931) | |
| Enumeration Date | 2012-05-25 |
| Last Update Date | 2021-06-25 |