| NPI | 1265679765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA182715) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA182715) |
| 363AM0700X Physician Assistant, Medical (Licence: DE C5-0000582) | |
| Enumeration Date | 2009-01-21 |
| Last Update Date | 2021-01-15 |