| NPI | 1528063807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2001032149) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 1019) |
| Enumeration Date | 2005-06-14 |
| Last Update Date | 2011-02-16 |