| NPI | 1407449234 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2021005613) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care |
| Enumeration Date | 2021-02-12 |
| Last Update Date | 2021-02-12 |