| NPI | 1871200329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 14246) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 8071-23) |
| Enumeration Date | 2022-11-03 |
| Last Update Date | 2024-10-03 |