| NPI | 1225401920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA185147) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9109254) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2015-11-04 |
| Last Update Date | 2018-11-09 |