| NPI | 1386743151 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10807) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SD 0547) |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2020-09-17 |