| NPI | 1215309521 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA214380) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 54019) |
| 363AM0700X Physician Assistant, Medical (Licence: OR PA214380) | |
| Enumeration Date | 2015-10-26 |
| Last Update Date | 2024-09-10 |