| NPI | 1780183574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MN 12614) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 12614) |
| Enumeration Date | 2018-02-07 |
| Last Update Date | 2019-12-24 |