| NPI | 1881971836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA161246) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OK 2049) |
| Enumeration Date | 2011-11-04 |
| Last Update Date | 2013-05-30 |