| NPI | 1528517687 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13313) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 3905) |
| 363A00000X Physician Assistant (Licence: WI 3905-23) | |
| Enumeration Date | 2016-09-29 |
| Last Update Date | 2022-10-20 |