| NPI | 1073824751 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10744) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1430) |
| Enumeration Date | 2010-06-28 |
| Last Update Date | 2017-10-12 |