| NPI | 1780394056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14317) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 7186-23) |
| 363AM0700X Physician Assistant, Medical (Licence: WI 7186) | |
| 363AS0400X Physician Assistant, Surgical (Licence: WI 7186) | |
| Enumeration Date | 2022-11-28 |
| Last Update Date | 2025-01-08 |