| NPI | 1235541376 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA177382) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2014-05-23 |
| Last Update Date | 2022-05-09 |