| NPI | 1740207380 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11661) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ND PAC0164) |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2017-05-04 |