| NPI | 1821351255 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11391) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SD 0820) |
| Enumeration Date | 2012-06-20 |
| Last Update Date | 2016-04-15 |