| NPI | 1558651158 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA172310) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA1723210) |
| Enumeration Date | 2011-04-15 |
| Last Update Date | 2024-11-05 |