| NPI | 1861478216 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110000927) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA219354) |
| Enumeration Date | 2005-12-19 |
| Last Update Date | 2024-04-19 |