| NPI | 1235324708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA01277) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR LL17393) |
| 363A00000X Physician Assistant (Licence: CO 0004251) | |
| Enumeration Date | 2007-09-07 |
| Last Update Date | 2020-11-11 |