| NPI | 1265510622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10806) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1456) |
| 363A00000X Physician Assistant (Licence: WA PA10004389) | |
| Enumeration Date | 2006-11-02 |
| Last Update Date | 2020-08-21 |