| NPI | 1629500285 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-01988) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-03-31 |
| Last Update Date | 2020-03-18 |