| NPI | 1073921813 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA208495) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA208495) |
| 363AS0400X Physician Assistant, Surgical (Licence: WA PA60493055) | |
| Enumeration Date | 2014-07-24 |
| Last Update Date | 2023-12-26 |