| NPI | 1912983941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 9201) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 22301) |
| Enumeration Date | 2005-12-21 |
| Last Update Date | 2024-01-18 |