| NPI | 1588111371 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12421) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 6483) |
| Enumeration Date | 2016-09-08 |
| Last Update Date | 2022-04-22 |