| NPI | 1821213257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-00754) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2005036215) |
| Enumeration Date | 2007-04-13 |
| Last Update Date | 2022-10-25 |