| NPI | 1063033801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: IA 136624) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA203570) |
| Enumeration Date | 2020-05-04 |
| Last Update Date | 2026-05-18 |