| NPI | 1649990409 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA227357) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NV PA3085) |
| Enumeration Date | 2022-08-31 |
| Last Update Date | 2025-12-02 |