| NPI | 1891137352 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13555) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 23106) |
| Enumeration Date | 2013-07-25 |
| Last Update Date | 2021-04-14 |