| NPI | 1447388608 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 1095) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 733) |
| 363A00000X Physician Assistant (Licence: KS 15-01049) | |
| 363A00000X Physician Assistant (Licence: IA 1870) | |
| Enumeration Date | 2007-03-01 |
| Last Update Date | 2014-12-01 |