| NPI | 1508610072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14973) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208800000X Urology (Licence: MN 14973) | |
| Enumeration Date | 2024-04-12 |
| Last Update Date | 2024-08-21 |