| NPI | 1295013076 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA201332) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OK 2374) |
| Enumeration Date | 2011-07-28 |
| Last Update Date | 2021-09-17 |