| NPI | 1922653294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13785) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 7687) |
| Enumeration Date | 2019-08-05 |
| Last Update Date | 2021-08-17 |