| NPI | 1023493103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11930) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 5257-23) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2015-07-30 |
| Last Update Date | 2020-10-26 |