| NPI | 1932877404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13701) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: WI 5590-23) | |
| Enumeration Date | 2021-08-31 |
| Last Update Date | 2022-12-13 |