| NPI | 1558740803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 2266) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 7270) |
| Enumeration Date | 2015-05-20 |
| Last Update Date | 2023-08-17 |