| NPI | 1396770582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA00801) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OR PA00801) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2017-03-09 |