| NPI | 1073577953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 2247) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 377-023) |
| Enumeration Date | 2006-04-17 |
| Last Update Date | 2025-01-30 |