| NPI | 1164735494 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KS 1501380) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-01380) |
| Enumeration Date | 2010-07-15 |
| Last Update Date | 2020-01-20 |