| NPI | 1407228620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA197416) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 6240) |
| Enumeration Date | 2015-10-27 |
| Last Update Date | 2022-08-31 |