| NPI | 1720177751 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10211) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 919) |
| Enumeration Date | 2006-10-11 |
| Last Update Date | 2024-01-23 |