| NPI | 1831075415 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-03148) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2025-08-12 |
| Last Update Date | 2025-11-05 |