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 |