| NPI | 1356812291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA195905) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA 56220) |
| 363AM0700X Physician Assistant, Medical (Licence: OR PA195905) | |
| Enumeration Date | 2018-12-17 |
| Last Update Date | 2020-11-10 |