| NPI | 1003899527 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 9151) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MN 9151) |
| 363AM0700X Physician Assistant, Medical (Licence: WI 797) | |
| Enumeration Date | 2005-11-29 |
| Last Update Date | 2021-11-04 |