| NPI | 1518542810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14579) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 1208270) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-03-17 |
| Last Update Date | 2023-12-18 |