| NPI | 1043739360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2017035244) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-02041) |
| Enumeration Date | 2017-09-19 |
| Last Update Date | 2023-11-28 |