| NPI | 1720015118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10408) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 1984) |
| Enumeration Date | 2006-06-28 |
| Last Update Date | 2017-11-22 |