| NPI | 1730852377 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2021013043) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: MO 2021013043) |
| Enumeration Date | 2021-07-29 |
| Last Update Date | 2021-10-28 |