| NPI | 1649587593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS T02813) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KS 15-01446) |
| 363AS0400X Physician Assistant, Surgical (Licence: KS 15-01446) | |
| Enumeration Date | 2010-09-13 |
| Last Update Date | 2023-09-18 |