| NPI | 1417538174 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14162) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 56010440) |
| Enumeration Date | 2021-04-15 |
| Last Update Date | 2023-01-03 |