| NPI | 1750634218 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA178695) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 015987) |
| Enumeration Date | 2012-10-22 |
| Last Update Date | 2017-01-30 |