| NPI | 1518053511 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA175642) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OR PA) |
| 363A00000X Physician Assistant (Licence: KS 0325344) | |
| Enumeration Date | 2006-10-05 |
| Last Update Date | 2020-04-06 |