| NPI | 1841874377 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13643) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-2069) |
| Enumeration Date | 2021-05-11 |
| Last Update Date | 2025-09-23 |