| NPI | 1699790022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA01115) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA10004205) |
| Enumeration Date | 2006-07-13 |
| Last Update Date | 2021-02-16 |