| NPI | 1710943402 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA155381) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10004581) |
| 363A00000X Physician Assistant (Licence: MT 49843) | |
| Enumeration Date | 2006-04-22 |
| Last Update Date | 2022-07-07 |