| NPI | 1366544553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS PA-15-00156) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: KS LCPC-127) |
| 363AM0700X Physician Assistant Medical (Licence: KS PA-15-00156) | |
| Enumeration Date | 2006-09-01 |
| Last Update Date | 2010-12-22 |