| NPI | 1174690853 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 9175) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 1802) |
| Enumeration Date | 2006-11-29 |
| Last Update Date | 2021-07-23 |