| NPI | 1396288056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12922) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 4637-23) |
| Enumeration Date | 2016-11-29 |
| Last Update Date | 2022-03-02 |