| NPI | 1306590765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 15233) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 8958) |
| Enumeration Date | 2022-02-04 |
| Last Update Date | 2025-05-13 |