| NPI | 1124410121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA176498) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9108471) |
| Enumeration Date | 2015-02-27 |
| Last Update Date | 2023-04-28 |