| NPI | 1063428811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KS T-00858) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: KS APPLIED FOR TEMP) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2007-07-08 |