| NPI | 1962957670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13256) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 3875) |
| Enumeration Date | 2016-08-23 |
| Last Update Date | 2020-09-14 |