| NPI | 1770586950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 994) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-01008) |
| Enumeration Date | 2005-05-23 |
| Last Update Date | 2012-01-19 |