| NPI | 1821725615 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-03048) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OK 5478) |
| 363AM0700X Physician Assistant, Medical (Licence: MO 2025006240) | |
| Enumeration Date | 2022-08-02 |
| Last Update Date | 2026-06-08 |