| NPI | 1003219304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-01742) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2015022139) |
| Enumeration Date | 2014-09-30 |
| Last Update Date | 2021-07-08 |