| NPI | 1720435746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: KS 1501810) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110005992) |
| Enumeration Date | 2016-05-19 |
| Last Update Date | 2023-05-02 |