| NPI | 1396742896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 9820) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WI 1684) |
| 363AS0400X Physician Assistant, Surgical (Licence: MN 9820) | |
| Enumeration Date | 2005-06-30 |
| Last Update Date | 2023-06-30 |