| NPI | 1811981244 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MO 2016038179) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 1501007) |
| Enumeration Date | 2005-08-31 |
| Last Update Date | 2025-03-05 |