| NPI | 1003624545 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA224199) |
| Enumeration Date | 2024-12-30 |
| Last Update Date | 2025-05-30 |