| NPI | 1548679509 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12390) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 51741) |
| Enumeration Date | 2014-08-04 |
| Last Update Date | 2022-07-21 |