| NPI | 1063880995 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2018034963) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-01816) |
| 363AM0700X Physician Assistant, Medical (Licence: KS 15-01816) | |
| Enumeration Date | 2015-09-09 |
| Last Update Date | 2018-10-09 |