| NPI | 1639451693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA201916) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05381) |
| 363AM0700X Physician Assistant, Medical (Licence: MI 5601006174) | |
| Enumeration Date | 2011-09-15 |
| Last Update Date | 2024-08-01 |