| NPI | 1013270784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13836) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MN 9081) |
| Enumeration Date | 2012-06-19 |
| Last Update Date | 2021-10-18 |