| NPI | 1194702050 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-00878) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KS 1500878) |
| 363A00000X Physician Assistant (Licence: MO 2017026091) | |
| Enumeration Date | 2005-12-30 |
| Last Update Date | 2022-02-10 |