| NPI | 1215041934 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA195563) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 5746) |
| Enumeration Date | 2006-08-19 |
| Last Update Date | 2021-01-26 |