| NPI | 1336456102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA207983) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601005853) |
| Enumeration Date | 2010-09-01 |
| Last Update Date | 2022-03-16 |