| NPI | 1104689280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA218893) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2024-02-01 |
| Last Update Date | 2024-09-23 |