| NPI | 1902151228 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MN 11189) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MN 1762) |
| Enumeration Date | 2012-07-24 |
| Last Update Date | 2013-10-14 |