| NPI | 1245878255 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MO 2021030022) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2019-12-20 |
| Last Update Date | 2025-01-30 |