| NPI | 1376660597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA00709) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA00709) |
| Enumeration Date | 2007-03-23 |
| Last Update Date | 2010-11-02 |