| NPI | 1164781555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA224251) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2012-05-07 |
| Last Update Date | 2026-02-25 |