| NPI | 1902153125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11170) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C04769) |
| Enumeration Date | 2012-08-07 |
| Last Update Date | 2020-09-15 |