| NPI | 1629380241 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10803) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1441) |
| Enumeration Date | 2010-07-12 |
| Last Update Date | 2020-10-09 |