| NPI | 1063433993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10155) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 891) |
| Enumeration Date | 2006-07-23 |
| Last Update Date | 2020-08-21 |