| NPI | 1891252680 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KS 15-02556) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 56568) |
| 363AM0700X Physician Assistant, Medical (Licence: CA 56568) | |
| Enumeration Date | 2019-02-27 |
| Last Update Date | 2021-11-29 |