| NPI | 1124091095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA202279) |
| Additional Taxonomies | 208VP0000X Pain Medicine Pain Medicine (Licence: OR PA202279) |
| 363AS0400X Physician Assistant Surgical (Licence: CA PA16612) | |
| Enumeration Date | 2006-02-09 |
| Last Update Date | 2023-11-03 |