| NPI | 1366488587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 00062924) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 00062701) |
| Enumeration Date | 2006-06-22 |
| Last Update Date | 2021-05-05 |