| NPI | 1154403160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-01048) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2006006977) |
| Enumeration Date | 2006-10-19 |
| Last Update Date | 2016-08-03 |