| NPI | 1245612696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA172334) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2015-06-22 |
| Last Update Date | 2021-03-18 |