| NPI | 1801506183 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2022046412) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: MO pending) | |
| Enumeration Date | 2022-11-28 |
| Last Update Date | 2022-12-30 |