| NPI | 1265859011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12491) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA PA4951) |
| Enumeration Date | 2014-03-18 |
| Last Update Date | 2020-03-10 |