| NPI | 1700510534 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14399) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 7220) |
| Enumeration Date | 2022-07-16 |
| Last Update Date | 2023-04-14 |