| NPI | 1023656782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA1824) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA207) |
| Enumeration Date | 2019-12-12 |
| Last Update Date | 2026-01-13 |