| NPI | 1598125817 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12098) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 7307-23) |
| Enumeration Date | 2016-02-29 |
| Last Update Date | 2025-12-16 |