| NPI | 1366457038 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KS 15-00862) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MO 2008018557) |
| Enumeration Date | 2006-07-30 |
| Last Update Date | 2008-10-09 |