| NPI | 1649220021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KS 15-00959) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MO 2004029282) |
| Enumeration Date | 2006-05-10 |
| Last Update Date | 2022-09-30 |