| NPI | 1891787131 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MN 10848) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 1402) |
| 363A00000X Physician Assistant (Licence: MN 10848) | |
| Enumeration Date | 2005-08-22 |
| Last Update Date | 2019-10-04 |