| NPI | 1598793036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 102464) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA00744) |
| 363A00000X Physician Assistant (Licence: OK 4558) | |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2021-09-27 |