| NPI | 1043988447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA204341) |
| Additional Taxonomies | 208800000X Urology (Licence: OR 204341) |
| Enumeration Date | 2021-08-31 |
| Last Update Date | 2025-08-20 |