| NPI | 1831460922 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA182471) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 002262) |
| Enumeration Date | 2012-01-20 |
| Last Update Date | 2024-01-05 |