| NPI | 1124448964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110005595) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA225085) |
| Enumeration Date | 2014-04-20 |
| Last Update Date | 2025-06-15 |