| NPI | 1265995658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA10012) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2019-04-11 |
| Last Update Date | 2023-01-24 |