| NPI | 1619486669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 2846) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OK Student) |
| Enumeration Date | 2017-09-21 |
| Last Update Date | 2017-12-28 |