| NPI | 1912972175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AK 944) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OR pa00769) |
| Enumeration Date | 2006-02-21 |
| Last Update Date | 2011-03-01 |