| NPI | 1104259456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11404) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 3207-23) |
| 363AM0700X Physician Assistant, Medical (Licence: MN 11404) | |
| Enumeration Date | 2013-08-09 |
| Last Update Date | 2024-06-24 |