| NPI | 1972522852 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA187333) |
| 363A00000X Physician Assistant (Licence: TX PA01858) | |
| 363A00000X Physician Assistant (Licence: WA PA60310501) | |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2021-01-25 |