| NPI | 1518220425 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11317) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 2921) |
| Enumeration Date | 2012-06-18 |
| Last Update Date | 2021-05-25 |