| NPI | 1679058754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2022037500) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 022615) |
| Enumeration Date | 2018-09-25 |
| Last Update Date | 2023-01-18 |