| NPI | 1770115727 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14115) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 005360) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-02-07 |
| Last Update Date | 2022-08-15 |