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 |