| NPI | 1861965774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12893) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 4600-23) |
| Enumeration Date | 2019-01-03 |
| Last Update Date | 2023-10-02 |