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 |