| NPI | 1629204532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10597) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1274) |
| Enumeration Date | 2009-06-05 |
| Last Update Date | 2020-08-24 |