| NPI | 1669809497 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 1501649) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KS 15-01649) |
| Enumeration Date | 2013-10-14 |
| Last Update Date | 2021-12-08 |