| NPI | 1750371456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-02047) |
| Enumeration Date | 2005-10-24 |
| Last Update Date | 2025-03-25 |