| NPI | 1194745984 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: OR MD190722) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OR PA00856) |
| Enumeration Date | 2006-07-21 |
| Last Update Date | 2026-06-09 |