| NPI | 1821657263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA212932) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2019-06-10 |
| Last Update Date | 2022-11-14 |