| NPI | 1548716459 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA215060) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9109752) |
| Enumeration Date | 2016-08-31 |
| Last Update Date | 2023-03-31 |