| NPI | 1659757193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA180241) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OR PA180241) |
| Enumeration Date | 2015-08-06 |
| Last Update Date | 2019-10-28 |