| NPI | 1285636605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KS 15-00908) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MO 2017004545) |
| Enumeration Date | 2005-08-15 |
| Last Update Date | 2022-09-30 |