| NPI | 1881164739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA191687) |
| 363A00000X Physician Assistant (Licence: NV 1158708) | |
| Enumeration Date | 2018-12-04 |
| Last Update Date | 2019-12-10 |