| NPI | 1154839785 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA210939) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MD C0006675) |
| Enumeration Date | 2018-01-17 |
| Last Update Date | 2023-02-09 |