| NPI | 1073112009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13656) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 5415) |
| Enumeration Date | 2020-10-21 |
| Last Update Date | 2025-09-08 |