| NPI | 1235687013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA179787) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: OR 179787) |
| Enumeration Date | 2016-09-21 |
| Last Update Date | 2023-11-01 |