| NPI | 1821403635 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11682) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MN 2102) |
| Enumeration Date | 2014-07-01 |
| Last Update Date | 2025-05-05 |