| NPI | 1962674705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 10531) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2014-0066) |
| Enumeration Date | 2008-04-01 |
| Last Update Date | 2017-05-08 |