| NPI | 1013286335 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA168476) | 
| Additional Taxonomies | 208VP0000X (Licence: OR PA168476) | 
| 208VP0014X Pain Medicine, Interventional Pain Medicine (Licence: OR PA168476) | |
| Enumeration Date | 2011-12-14 | 
| Last Update Date | 2025-05-21 |