| NPI | 1699446815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA208605) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-2012) |
| Enumeration Date | 2021-09-27 |
| Last Update Date | 2024-03-19 |