| NPI | 1497435630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA218473) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 13505002-1206) |
| 207Q00000X Family Medicine (Licence: OR PA218473) | |
| Enumeration Date | 2023-07-21 |
| Last Update Date | 2023-12-07 |