| NPI | 1891218095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13002) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 4083) |
| Enumeration Date | 2017-07-19 |
| Last Update Date | 2019-06-03 |