| NPI | 1588776736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10249) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 1781) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2024-02-14 |