| NPI | 1477391357 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 6361826) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA224957) |
| Enumeration Date | 2024-07-16 |
| Last Update Date | 2026-01-14 |