| NPI | 1740803576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2020037118) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 1502398) |
| Enumeration Date | 2020-05-27 |
| Last Update Date | 2024-05-29 |