| NPI | 1942993068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 15211) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-13343) |
| Enumeration Date | 2023-06-02 |
| Last Update Date | 2025-04-16 |