| NPI | 1730713033 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2020006739) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-02694) |
| Enumeration Date | 2020-02-25 |
| Last Update Date | 2024-07-30 |