| NPI | 1255619813 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11508) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MN 11508) |
| 363AS0400X Physician Assistant, Surgical (Licence: MN 11508) | |
| Enumeration Date | 2011-08-01 |
| Last Update Date | 2020-10-01 |