| NPI | 1861821365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11500) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID 7161776) |
| Enumeration Date | 2013-11-05 |
| Last Update Date | 2025-09-16 |