| NPI | 1932764222 |
|---|---|
| Professional Name | NA NA NA |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11974) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA201572) |
| Enumeration Date | 2019-05-02 |
| Last Update Date | 2023-02-02 |