| NPI | 1013165638 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MN 10477) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1169- temp) |
| Enumeration Date | 2008-09-08 |
| Last Update Date | 2022-03-03 |