| NPI | 1023501491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA195734) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA195734) |
| Enumeration Date | 2018-06-11 |
| Last Update Date | 2020-12-21 |