| NPI | 1548711369 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KS 15-01955) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MO 2017003700) |
| Enumeration Date | 2016-10-17 |
| Last Update Date | 2025-12-07 |