| NPI | 1487028627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12377) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-06080) |
| Enumeration Date | 2015-11-28 |
| Last Update Date | 2024-01-15 |