| NPI | 1083203491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA220563) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2021-01-12 |
| Last Update Date | 2024-06-27 |