| NPI | 1376570440 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: OR PA01356) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: ID PA549) |
| Enumeration Date | 2006-06-26 |
| Last Update Date | 2024-01-08 |