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 |