| NPI | 1316364185 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 15011) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2014005126) |
| Enumeration Date | 2014-03-18 |
| Last Update Date | 2025-11-19 |