| NPI | 1629284641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR pa152971) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 2899) |
| Enumeration Date | 2007-05-15 |
| Last Update Date | 2020-04-24 |