| NPI | 1609599950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 15032) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 8068) |
| Enumeration Date | 2022-09-21 |
| Last Update Date | 2024-09-22 |