| NPI | 1124443320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA178579) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 7127) |
| Enumeration Date | 2014-02-25 |
| Last Update Date | 2017-02-20 |