| NPI | 1750784039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA17081) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA170181) |
| Enumeration Date | 2014-10-01 |
| Last Update Date | 2024-08-16 |