| NPI | 1740317387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MN 12693) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-42955) | |
| Enumeration Date | 2007-02-28 |
| Last Update Date | 2018-09-18 |