| NPI | 1962824359 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MO 2014002999) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2014002999) |
| Enumeration Date | 2014-01-20 |
| Last Update Date | 2019-10-24 |