| NPI | 1740617729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA172141) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA056511) |
| Enumeration Date | 2013-10-04 |
| Last Update Date | 2020-11-10 |