| NPI | 1154080562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 15431) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 4915) |
| Enumeration Date | 2021-12-13 |
| Last Update Date | 2026-01-30 |