| NPI | 1235441833 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA222474) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 014022) |
| 363A00000X Physician Assistant (Licence: PA MA056417) | |
| Enumeration Date | 2010-07-12 |
| Last Update Date | 2026-01-07 |