| NPI | 1689093346 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11618) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 2077) |
| Enumeration Date | 2014-04-09 |
| Last Update Date | 2022-06-09 |