| NPI | 1235401761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA181331) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX 1102211) |
| Enumeration Date | 2012-01-30 |
| Last Update Date | 2025-12-08 |