| NPI | 1801204821 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA191668) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: WY PA609) |
| 363AS0400X Physician Assistant Surgical | |
| Enumeration Date | 2014-07-23 |
| Last Update Date | 2019-05-21 |