| NPI | 1457606618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2012021523) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 1501587) |
| Enumeration Date | 2012-07-13 |
| Last Update Date | 2024-08-29 |