| NPI | 1942789888 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 12775) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA059968) |
| Enumeration Date | 2018-08-10 |
| Last Update Date | 2025-02-21 |