| NPI | 1447812268 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA196278) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2019-07-01 |
| Last Update Date | 2019-12-09 |