| NPI | 1831126788 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2002024940) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 1501284) |
| Enumeration Date | 2006-06-27 |
| Last Update Date | 2021-08-12 |