| NPI | 1083006753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14197) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2015006472) |
| Enumeration Date | 2015-03-04 |
| Last Update Date | 2023-05-22 |