| NPI | 1861260234 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-02903) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2024006222) |
| Enumeration Date | 2023-12-15 |
| Last Update Date | 2026-06-10 |