| NPI | 1730635574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2020008278) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-02340) |
| 363A00000X Physician Assistant (Licence: IA 083606) | |
| Enumeration Date | 2016-08-31 |
| Last Update Date | 2024-10-24 |