| NPI | 1225099815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA157583) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CA 6775) |
| Enumeration Date | 2006-03-31 |
| Last Update Date | 2022-07-21 |