| NPI | 1700112646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA150483) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA150483) |
| Enumeration Date | 2009-10-28 |
| Last Update Date | 2013-11-08 |