| NPI | 1245680214 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13868) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA196165) |
| 363AS0400X Physician Assistant, Surgical (Licence: OR PA196165) | |
| Enumeration Date | 2016-06-20 |
| Last Update Date | 2022-12-27 |