| NPI | 1295737997 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA00390) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OR PA00390) |
| Enumeration Date | 2005-08-11 |
| Last Update Date | 2019-02-07 |