| NPI | 1962482042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA184052) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA 14456) |
| Enumeration Date | 2006-01-17 |
| Last Update Date | 2018-03-17 |