| NPI | 1972288819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 15218) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 15218) |
| Enumeration Date | 2023-06-19 |
| Last Update Date | 2025-02-19 |