| NPI | 1932152170 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2009009267) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15) |
| Enumeration Date | 2006-05-18 |
| Last Update Date | 2025-06-17 |