| NPI | 1245750405 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 4158) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 12501) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-06-20 |
| Last Update Date | 2021-08-24 |