| NPI | 1366425399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10108) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MN 10108) |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 3026) | |
| Enumeration Date | 2005-11-23 |
| Last Update Date | 2020-08-21 |