| NPI | 1457811184 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-104135) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA195002) |
| Enumeration Date | 2019-03-20 |
| Last Update Date | 2025-04-09 |