| NPI | 1194426254 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 15081) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 8134-23) |
| Enumeration Date | 2023-03-15 |
| Last Update Date | 2025-11-20 |