| NPI | 1801815550 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2020004735) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 2243) |
| 363A00000X Physician Assistant (Licence: KS 15-02332) | |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2025-10-29 |