| NPI | 1700125796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12530) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 6339) |
| Enumeration Date | 2013-02-11 |
| Last Update Date | 2017-10-20 |