| NPI | 1295200327 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14104) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 7089-23) |
| 363A00000X Physician Assistant | |
| 363A00000X Physician Assistant (Licence: CO PA.0005591) | |
| Enumeration Date | 2018-10-04 |
| Last Update Date | 2022-09-26 |