| NPI | 1114976057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: KS 15-00772) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MO 2001023404) |
| 363AS0400X Physician Assistant, Surgical (Licence: MO 2001023404) | |
| 363AS0400X Physician Assistant, Surgical (Licence: KS 15-00772) | |
| Enumeration Date | 2006-05-08 |
| Last Update Date | 2011-05-17 |