| NPI | 1770665101 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: KS 1501063) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: MO 2005032882) |
| Enumeration Date | 2006-10-19 |
| Last Update Date | 2013-04-09 |