| NPI | 1396968202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-138573) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA01016) |
| Enumeration Date | 2007-04-10 |
| Last Update Date | 2024-11-12 |