| NPI | 1457907180 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2807) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: OR PA196037) | |
| Enumeration Date | 2019-08-19 |
| Last Update Date | 2024-06-24 |