| NPI | 1568630135 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA150453) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CT 002061) |
| Enumeration Date | 2008-02-15 |
| Last Update Date | 2020-05-29 |