| NPI | 1053075077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA207912) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA60273) |
| Enumeration Date | 2021-10-26 |
| Last Update Date | 2023-01-24 |