| NPI | 1073520581 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA214173) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10003694) |
| 363A00000X Physician Assistant (Licence: CA PA22496) | |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA10003694) | |
| 363AS0400X Physician Assistant, Surgical (Licence: CA PA22496) | |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2026-03-18 |