| NPI | 1174885974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11175) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1770) |
| Enumeration Date | 2012-06-08 |
| Last Update Date | 2020-08-21 |