| NPI | 1992022693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR 196530) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 005820) |
| Enumeration Date | 2010-04-21 |
| Last Update Date | 2020-02-13 |