| NPI | 1740912096 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14814) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 7776-23) |
| Enumeration Date | 2022-06-27 |
| Last Update Date | 2026-05-01 |