| NPI | 1346205697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 15436) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.002588) |
| Enumeration Date | 2006-04-19 |
| Last Update Date | 2025-10-16 |