| NPI | 1578782975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: OR PA00684) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA00684) |
| Enumeration Date | 2007-04-24 |
| Last Update Date | 2008-07-29 |