| NPI | 1619782190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 15618) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 363A00000X Physician Assistant (Licence: ND PAC1172) | |
| Enumeration Date | 2025-02-11 |
| Last Update Date | 2026-02-11 |