| NPI | 1801167556 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MO 2012010358) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MO 2012010358) |
| 363AM0700X Physician Assistant, Medical (Licence: KS 15-01527) | |
| Enumeration Date | 2012-01-25 |
| Last Update Date | 2021-01-07 |