| NPI | 1407014335 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA210603) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 012362-1) |
| Enumeration Date | 2008-05-28 |
| Last Update Date | 2024-07-16 |