| NPI | 1467195826 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA218276) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9115705) |
| Enumeration Date | 2022-04-14 |
| Last Update Date | 2023-11-10 |