| NPI | 1013375567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA210116) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: OR 20953) |
| Enumeration Date | 2016-01-28 |
| Last Update Date | 2025-09-11 |