| NPI | 1942596846 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10928) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1572) |
| Enumeration Date | 2011-06-20 |
| Last Update Date | 2017-02-05 |