| NPI | 1588270136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13979) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: WI 22186) | |
| Enumeration Date | 2020-09-18 |
| Last Update Date | 2024-07-16 |