| NPI | 1568087534 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA217556) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: OR PA217556) |
| Enumeration Date | 2020-06-15 |
| Last Update Date | 2024-06-24 |