| NPI | 1528399714 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA169146) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: MI 5601005692) |
| Enumeration Date | 2010-01-27 |
| Last Update Date | 2023-10-18 |