| NPI | 1891856159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2008021981) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-00968) |
| 363AS0400X Physician Assistant, Surgical (Licence: MO 2008021981) | |
| 363AS0400X Physician Assistant, Surgical (Licence: KS 15-00968) | |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2019-04-09 |