| NPI | 1932158953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR pa00402) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OR pa00402) |
| Enumeration Date | 2006-05-08 |
| Last Update Date | 2021-02-05 |