| NPI | 1316346307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11969) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 074607) |
| Enumeration Date | 2014-08-15 |
| Last Update Date | 2020-09-18 |