| NPI | 1154738003 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA196034) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1118471) |
| Enumeration Date | 2014-07-11 |
| Last Update Date | 2023-09-06 |