| NPI | 1831740059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 3153) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: LA 344870) |
| Enumeration Date | 2019-09-29 |
| Last Update Date | 2026-05-15 |