| NPI | 1003864927 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA01083) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: HI AMD-445) |
| Enumeration Date | 2006-05-04 |
| Last Update Date | 2023-01-24 |