| NPI | 1922564822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 3752) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 12934) |
| Enumeration Date | 2019-02-15 |
| Last Update Date | 2022-10-28 |