| NPI | 1295043263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: OR PA166538) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 002653) |
| 363A00000X Physician Assistant (Licence: NM PA-2010-0055) | |
| Enumeration Date | 2010-09-23 |
| Last Update Date | 2020-12-23 |