| NPI | 1831578707 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13663) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020331) |
| Enumeration Date | 2015-05-26 |
| Last Update Date | 2023-06-23 |