| NPI | 1962584706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11279) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 1843) |
| 363AS0400X Physician Assistant, Surgical (Licence: MN 11279) | |
| Enumeration Date | 2006-10-20 |
| Last Update Date | 2016-07-21 |