| NPI | 1447587027 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KS 1502009) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KS 15-02009) |
| 363AS0400X Physician Assistant, Surgical (Licence: OR PA150409) | |
| Enumeration Date | 2009-11-03 |
| Last Update Date | 2020-03-04 |