| NPI | 1700893088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA188995) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-458) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2024-10-28 |