| NPI | 1508808528 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA002700) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 1501096) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA001513L) | |
| 363AM0700X Physician Assistant, Medical (Licence: KS 1501096) | |
| 363AS0400X Physician Assistant, Surgical (Licence: KS 1501096) | |
| Enumeration Date | 2006-06-12 |
| Last Update Date | 2022-04-29 |