| NPI | 1164759528 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10914) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 4093) |
| Enumeration Date | 2009-11-05 |
| Last Update Date | 2024-05-16 |