| NPI | 1053853275 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13853) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: MN 993204) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 2000026655) | |
| Enumeration Date | 2016-11-07 |
| Last Update Date | 2021-10-04 |