| NPI | 1871015909 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA187403) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 54623) |
| Enumeration Date | 2017-07-11 |
| Last Update Date | 2020-01-10 |