| NPI | 1568421758 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KS 0426923) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2009025417) |
| Enumeration Date | 2006-03-17 |
| Last Update Date | 2021-12-06 |