| NPI | 1639523210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 3276) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA227694) |
| Enumeration Date | 2016-04-20 |
| Last Update Date | 2026-01-24 |