| NPI | 1801852827 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA208752) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 3405) |
| Enumeration Date | 2006-04-26 |
| Last Update Date | 2022-10-05 |