| NPI | 1750782157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: OR PA169587) |
| Enumeration Date | 2014-09-05 |
| Last Update Date | 2016-06-06 |