| NPI | 1376667063 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14525) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 1117331) |
| 363A00000X Physician Assistant (Licence: WI 7809) | |
| Enumeration Date | 2007-03-19 |
| Last Update Date | 2025-01-07 |