| 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 |