| NPI | 1457356800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MN 10852) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 1826) |
| Enumeration Date | 2005-06-14 |
| Last Update Date | 2017-10-03 |