| NPI | 1033191630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA01431) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085001753) |
| 363AS0400X Physician Assistant Surgical (Licence: OR PA01431) | |
| Enumeration Date | 2005-11-18 |
| Last Update Date | 2020-02-26 |