| NPI | 1639253420 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA203843) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MA 1167) |
| Enumeration Date | 2006-10-25 |
| Last Update Date | 2021-06-17 |