| NPI | 1295475176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 129628) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-02602) |
| Enumeration Date | 2022-03-30 |
| Last Update Date | 2025-04-11 |