| NPI | 1245534262 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AK 118994) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA151199) |
| Enumeration Date | 2011-01-05 |
| Last Update Date | 2018-03-17 |