| NPI | 1245853373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA211370) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 10701) |
| Enumeration Date | 2020-05-22 |
| Last Update Date | 2025-10-20 |