| NPI | 1790729630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-00868) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: KS 1500868) |
| Enumeration Date | 2006-06-15 |
| Last Update Date | 2023-07-10 |