| NPI | 1235623455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12790) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 4375-23) |
| Enumeration Date | 2018-06-20 |
| Last Update Date | 2020-06-08 |