| NPI | 1831220052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA199574) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA 2815) |
| Enumeration Date | 2007-03-08 |
| Last Update Date | 2022-07-20 |