NPI | 1003255381 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11438) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1985) |
363AM0700X Physician Assistant, Medical (Licence: WI 3157-23) | |
Enumeration Date | 2013-06-19 |
Last Update Date | 2023-12-06 |