| NPI | 1174913123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-01775) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2015013517) |
| Enumeration Date | 2015-01-29 |
| Last Update Date | 2017-04-19 |