| NPI | 1235402322 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA205778) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA22123) |
| Enumeration Date | 2012-02-20 |
| Last Update Date | 2022-10-05 |