| NPI | 1053783316 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA174983) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA174983) |
| Enumeration Date | 2015-10-27 |
| Last Update Date | 2020-12-18 |