| NPI | 1457519829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: OR PA 153108) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CA PA 19589) |
| Enumeration Date | 2008-06-02 |
| Last Update Date | 2016-12-12 |