| NPI | 1700858693 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-02453) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 1247) |
| 363A00000X Physician Assistant (Licence: MT 141404) | |
| Enumeration Date | 2006-02-03 |
| Last Update Date | 2024-09-06 |