| NPI | 1952565830 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10931) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: IA 001925) |
| 363A00000X Physician Assistant (Licence: IA 001925) | |
| Enumeration Date | 2008-07-10 |
| Last Update Date | 2020-11-19 |