| NPI | 1699233965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA204810) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 12945) |
| Enumeration Date | 2019-03-06 |
| Last Update Date | 2023-04-25 |