| NPI | 1144380296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10183) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MN 936) |
| Enumeration Date | 2006-12-11 |
| Last Update Date | 2013-02-06 |