| NPI | 1023748779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA225698) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9116144) |
| Enumeration Date | 2022-06-15 |
| Last Update Date | 2025-07-15 |