| NPI | 1982030987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 082773) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 13358) |
| 363A00000X Physician Assistant (Licence: NC 0010-04519) | |
| Enumeration Date | 2013-09-23 |
| Last Update Date | 2025-04-16 |