| NPI | 1306394226 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 82316) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA179863) |
| Enumeration Date | 2016-09-20 |
| Last Update Date | 2021-04-16 |