| NPI | 1184624223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA01458) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 85080883) |
| Enumeration Date | 2005-07-29 |
| Last Update Date | 2021-03-29 |