| NPI | 1346447851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA01090) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 310) |
| Enumeration Date | 2007-06-28 |
| Last Update Date | 2021-11-29 |