| NPI | 1972589695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1053751) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-01189) |
| Enumeration Date | 2005-12-15 |
| Last Update Date | 2024-01-11 |