| NPI | 1366884991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11573) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 002425) |
| Enumeration Date | 2013-07-24 |
| Last Update Date | 2016-09-07 |