| NPI | 1700389798 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 1502179) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 0005198) |
| Enumeration Date | 2018-03-15 |
| Last Update Date | 2021-01-28 |