| NPI | 1528595170 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-01978) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2017002625) |
| Enumeration Date | 2017-05-15 |
| Last Update Date | 2022-07-21 |