| NPI | 1871566646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2020000890) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-00932) |
| Enumeration Date | 2006-02-10 |
| Last Update Date | 2021-06-03 |