| NPI | 1760441463 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MN 10891) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 1614) |
| Enumeration Date | 2006-03-21 |
| Last Update Date | 2025-05-09 |