| NPI | 1154831642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: KS 15-03060) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MO 2017036354) |
| Enumeration Date | 2017-10-10 |
| Last Update Date | 2025-07-02 |