| NPI | 1033634001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12851) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C06566) |
| Enumeration Date | 2017-08-10 |
| Last Update Date | 2020-10-09 |