| NPI | 1902220213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-04859) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA203040) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2014-02-06 |
| Last Update Date | 2023-02-08 |