| NPI | 1952024374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 15031) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 8198) |
| Enumeration Date | 2022-09-21 |
| Last Update Date | 2024-11-19 |