| NPI | 1740632355 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14420) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 2727) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2016-07-07 |
| Last Update Date | 2023-05-17 |