| NPI | 1487491296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2024033406) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical |
| Enumeration Date | 2024-07-09 |
| Last Update Date | 2024-09-06 |