| NPI | 1952640799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11302) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 1867) |
| Enumeration Date | 2013-02-13 |
| Last Update Date | 2018-02-02 |