| NPI | 1790896116 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MO 2023013710) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2023013710) |
| 363A00000X Physician Assistant (Licence: KS 53-82150-062) | |
| 363AS0400X Physician Assistant, Surgical (Licence: KS 15-00759) | |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2025-06-11 |