| NPI | 1881980191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11429) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA054940) |
| Enumeration Date | 2011-06-24 |
| Last Update Date | 2025-03-20 |