| NPI | 1871954750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR 188520) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: HI amd-797) |
| 363AM0700X Physician Assistant, Medical (Licence: AK 105989) | |
| Enumeration Date | 2016-03-18 |
| Last Update Date | 2021-06-09 |