| NPI | 1407137334 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA194316) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 2782023) |
| 363A00000X Physician Assistant (Licence: CA PA66213) | |
| Enumeration Date | 2011-09-06 |
| Last Update Date | 2025-04-18 |