| NPI | 1225365687 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA155998) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 596) |
| Enumeration Date | 2009-11-05 |
| Last Update Date | 2020-11-11 |