| NPI | 1588898035 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MN 10630) | 
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WI 2473-23) | 
| 363AS0400X Physician Assistant, Surgical (Licence: MN 10630) | |
| Enumeration Date | 2009-05-13 | 
| Last Update Date | 2025-09-03 |