| NPI | 1215357108 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11596) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MN 11596) |
| 363AS0400X Physician Assistant, Surgical (Licence: WI 3312-23) | |
| Enumeration Date | 2014-04-18 |
| Last Update Date | 2026-04-20 |