| NPI | 1376589598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 1501269) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2001005636) |
| Enumeration Date | 2006-06-22 |
| Last Update Date | 2012-01-05 |