| NPI | 1568183796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-03025) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2024046028) |
| Enumeration Date | 2022-09-06 |
| Last Update Date | 2025-04-28 |