| NPI | 1578002804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12630) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MO 2017004716) |
| Enumeration Date | 2017-02-20 |
| Last Update Date | 2020-10-09 |