| NPI | 1265577811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-886) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA211907) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2007-02-21 |
| Last Update Date | 2023-02-17 |