| NPI | 1760457493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 9766) |
| Additional Taxonomies | 174400000X Specialist (Licence: MN 9766) |
| Enumeration Date | 2006-02-17 |
| Last Update Date | 2020-08-24 |