| NPI | 1609229749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MN 12884) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IA 083572) |
| Enumeration Date | 2016-07-13 |
| Last Update Date | 2025-05-16 |