| NPI | 1154218006 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2025036081) | 
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-03142) | 
| Enumeration Date | 2025-06-23 | 
| Last Update Date | 2025-10-04 |