| NPI | 1063802015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA184897) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9108511) |
| Enumeration Date | 2015-01-29 |
| Last Update Date | 2020-04-28 |