| NPI | 1003128059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12317) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AM0700X Physician Assistant, Medical (Licence: WI 3095) | |
| Enumeration Date | 2010-07-07 |
| Last Update Date | 2020-10-09 |