| NPI | 1154706596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 44394) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA174030) |
| Enumeration Date | 2015-07-28 |
| Last Update Date | 2021-05-19 |