| NPI | 1376524694 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA152793) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0002340) |
| Enumeration Date | 2005-11-14 |
| Last Update Date | 2021-12-05 |