| NPI | 1417567082 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA201695) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-08-07 |
| Last Update Date | 2021-06-09 |