| NPI | 1861851172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: MN 12007) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 12007) |
| Enumeration Date | 2016-02-15 |
| Last Update Date | 2021-03-09 |