| NPI | 1780655472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MN 9489) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: MN 9489) |
| Enumeration Date | 2006-01-30 |
| Last Update Date | 2010-09-30 |