| NPI | 1467295618 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA224764) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 64971) |
| Enumeration Date | 2024-06-17 |
| Last Update Date | 2025-09-10 |