| NPI | 1881036143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11486) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical |
| Enumeration Date | 2013-07-26 |
| Last Update Date | 2021-03-12 |