| NPI | 1659883551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA185111) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA185111) |
| Enumeration Date | 2017-11-01 |
| Last Update Date | 2024-08-07 |