| NPI | 1245481761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA01392) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: OR PA01392) |
| Enumeration Date | 2008-10-02 |
| Last Update Date | 2021-10-19 |