| NPI | 1104356088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA211395) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA000813L) |
| Enumeration Date | 2017-06-14 |
| Last Update Date | 2022-08-11 |