| NPI | 1609293174 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA166641) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR 166641) |
| Enumeration Date | 2014-03-23 |
| Last Update Date | 2019-11-12 |