| NPI | 1992798060 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA00833) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OR PA00833) |
| 363AS0400X Physician Assistant, Surgical (Licence: WA PA10004741) | |
| Enumeration Date | 2005-08-24 |
| Last Update Date | 2019-11-19 |