| NPI | 1073884854 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA212515) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA21978) |
| Enumeration Date | 2012-01-25 |
| Last Update Date | 2022-10-06 |