| NPI | 1083946032 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10945) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: FL PA9105381) |
| Enumeration Date | 2010-02-02 |
| Last Update Date | 2012-09-07 |