| NPI | 1396706511 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 9658) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 1424-23) |
| 363AS0400X Physician Assistant Surgical (Licence: MN 9658) | |
| Enumeration Date | 2006-03-29 |
| Last Update Date | 2021-08-26 |