| NPI | 1811477359 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA202927) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: UT 11443778-1206) | |
| Enumeration Date | 2018-08-15 |
| Last Update Date | 2023-08-30 |