| NPI | 1134774730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13328) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2019-08-09 |
| Last Update Date | 2020-03-25 |