| NPI | 1033343355 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10737) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1403) |
| 363AM0700X Physician Assistant, Medical (Licence: GA 005573) | |
| Enumeration Date | 2009-05-14 |
| Last Update Date | 2020-08-21 |