| NPI | 1073946760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11477) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1966) |
| Enumeration Date | 2013-08-16 |
| Last Update Date | 2021-12-28 |