| NPI | 1114687621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OR PA213628) |
| Enumeration Date | 2021-12-23 |
| Last Update Date | 2024-01-25 |