| NPI | 1205866894 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12171) |
| Additional Taxonomies | 111N00000X Chiropractor (Licence: MN 4744) |
| Enumeration Date | 2006-07-03 |
| Last Update Date | 2017-05-02 |