| NPI | 1235420670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: MN 11440) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11440) |
| 363A00000X Physician Assistant (Licence: ND PAC0532) | |
| Enumeration Date | 2011-04-20 |
| Last Update Date | 2019-08-30 |