| NPI | 1528153434 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11417) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601004850) |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2013-10-22 |