| NPI | 1457770596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA00881) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OR PA00881) |
| Enumeration Date | 2014-04-15 |
| Last Update Date | 2014-04-15 |