| NPI | 1083695639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 866) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OK 866) |
| 363AS0400X Physician Assistant, Surgical (Licence: OK 866) | |
| Enumeration Date | 2005-11-10 |
| Last Update Date | 2019-08-09 |