| NPI | 1669620332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 2301) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 002141) |
| Enumeration Date | 2008-09-05 |
| Last Update Date | 2018-07-17 |