| NPI | 1194073387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA055674) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OR PA 165543) |
| 363A00000X Physician Assistant (Licence: OR PA165543) | |
| Enumeration Date | 2012-08-21 |
| Last Update Date | 2023-03-20 |