| NPI | 1427651967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2021009626) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MO 2021009626) |
| Enumeration Date | 2020-11-18 |
| Last Update Date | 2025-12-18 |