| NPI | 1568125912 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14935) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: ND PAC0996) | |
| Enumeration Date | 2021-10-21 |
| Last Update Date | 2024-09-09 |