| NPI | 1386927044 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA186105) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 4930) |
| Enumeration Date | 2011-09-20 |
| Last Update Date | 2023-05-25 |