| NPI | 1780918847 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA158690) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 4477) |
| 363AM0700X Physician Assistant, Medical (Licence: OR PA158690) | |
| Enumeration Date | 2009-09-22 |
| Last Update Date | 2023-08-07 |