| NPI | 1043705460 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 13732) |
| 363AS0400X Physician Assistant, Surgical (Licence: OR PA189454) | |
| Enumeration Date | 2018-06-27 |
| Last Update Date | 2022-05-11 |