| NPI | 1134195530 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10073) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1959) |
| 363A00000X Physician Assistant (Licence: WI 1959) | |
| Enumeration Date | 2006-02-24 |
| Last Update Date | 2021-04-07 |