| NPI | 1295030021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA 153698) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61044159) |
| 363A00000X Physician Assistant (Licence: ID PA-2310) | |
| Enumeration Date | 2011-01-26 |
| Last Update Date | 2022-08-10 |