| NPI | 1851763270 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA205181) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA60766799) |
| Enumeration Date | 2015-10-25 |
| Last Update Date | 2021-10-20 |