| NPI | 1700236692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA179177) |
| Additional Taxonomies | 174400000X Specialist (Licence: OR 179177) |
| Enumeration Date | 2016-06-21 |
| Last Update Date | 2023-01-11 |