| NPI | 1184906695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA PA21747) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA213714) |
| 363A00000X Physician Assistant (Licence: ID PA-2254) | |
| 363A00000X Physician Assistant (Licence: WA PA61013600) | |
| Enumeration Date | 2011-09-12 |
| Last Update Date | 2025-12-08 |