| NPI | 1124537998 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA217091) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA059255) |
| Enumeration Date | 2017-09-25 |
| Last Update Date | 2023-08-23 |