| NPI | 1659953792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA218626) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA2695) |
| Enumeration Date | 2021-04-27 |
| Last Update Date | 2024-04-16 |