| NPI | 1255329967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA00805) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA00805) |
| Enumeration Date | 2005-10-07 |
| Last Update Date | 2025-07-28 |