| NPI | 1467933481 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA198202) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 78954) |
| Enumeration Date | 2018-08-27 |
| Last Update Date | 2026-08-20 |