| NPI | 1215527346 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13655) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 5373) |
| Enumeration Date | 2021-01-22 |
| Last Update Date | 2023-07-28 |