| NPI | 1922053164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 4960) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2002012315) |
| Enumeration Date | 2006-05-24 |
| Last Update Date | 2023-05-19 |