| NPI | 1154913309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA229686) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA59587) |
| Enumeration Date | 2021-02-09 |
| Last Update Date | 2026-07-28 |