| NPI | 1982821922 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA158963) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA 1618) |
| 363AS0400X Physician Assistant, Surgical (Licence: WA PA60291947) | |
| Enumeration Date | 2007-04-19 |
| Last Update Date | 2015-09-09 |