| NPI | 1689104986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12466) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: MN 12466) |
| Enumeration Date | 2017-06-19 |
| Last Update Date | 2024-03-01 |