| NPI | 1497902274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA168574) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: ID PAT510) |
| Enumeration Date | 2008-08-22 |
| Last Update Date | 2021-11-12 |