| NPI | 1083082192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA181867) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 9517409-1206) |
| Enumeration Date | 2015-09-04 |
| Last Update Date | 2020-11-02 |