| NPI | 1023369527 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA208709) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA) |
| Enumeration Date | 2012-09-24 |
| Last Update Date | 2022-05-03 |