| NPI | 1508885021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 9399) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner Pediatrics (Licence: MN 91145) |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2013-04-17 |