| NPI | 1366802290 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12019) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 2390) |
| Enumeration Date | 2016-03-04 |
| Last Update Date | 2025-04-01 |