| NPI | 1720462039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA214134) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 7621) |
| Enumeration Date | 2015-07-16 |
| Last Update Date | 2023-06-20 |