| NPI | 1215971452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA151076) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA15090) |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2013-04-15 |