| NPI | 1467905570 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12734) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110-005469) |
| Enumeration Date | 2016-07-26 |
| Last Update Date | 2023-06-14 |