| NPI | 1275741175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12658) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: SD 0170) |
| 363A00000X Physician Assistant | |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2007-05-21 |
| Last Update Date | 2020-09-29 |