| NPI | 1508589771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA213864) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| Enumeration Date | 2022-09-22 |
| Last Update Date | 2026-07-20 |