| NPI | 1558760512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11675) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IA 074801) |
| Enumeration Date | 2014-08-15 |
| Last Update Date | 2022-06-20 |