| NPI | 1487676607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MN 10539) |
| Additional Taxonomies | 111NR0400X (Licence: MN 5235) |
| 363A00000X Physician Assistant (Licence: MN 10539) | |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2020-11-10 |