| NPI | 1043270440 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 9494) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 1875) |
| Enumeration Date | 2006-03-28 |
| Last Update Date | 2025-04-10 |