| NPI | 1477182160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13679) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 8469) |
| Enumeration Date | 2020-04-03 |
| Last Update Date | 2024-04-09 |