| NPI | 1982760260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: OR PA01146) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA01146) |
| Enumeration Date | 2006-12-29 |
| Last Update Date | 2020-12-31 |