| NPI | 1952688509 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: OK 2042) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 4930) |
| Enumeration Date | 2011-11-10 |
| Last Update Date | 2023-06-27 |