NPI | 1962957670 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13256) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 3875) |
Enumeration Date | 2016-08-23 |
Last Update Date | 2020-09-14 |