| NPI | 1366791675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 1501666) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 8414359-1206) |
| 363A00000X Physician Assistant (Licence: MD c05249) | |
| Enumeration Date | 2012-08-31 |
| Last Update Date | 2014-01-08 |