| NPI | 1225374580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA165813) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA PA22603) |
| Enumeration Date | 2012-12-13 |
| Last Update Date | 2014-05-21 |