| NPI | 1952449522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11144) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA051106) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA051106) | |
| Enumeration Date | 2007-02-03 |
| Last Update Date | 2019-07-30 |