| NPI | 1972190759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 13629) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 5402) |
| Enumeration Date | 2020-12-28 |
| Last Update Date | 2023-02-15 |