| NPI | 1730639477 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-70872) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA180024) |
| Enumeration Date | 2016-10-05 |
| Last Update Date | 2019-02-25 |