| NPI | 1659608172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 142655) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA150149) |
| Enumeration Date | 2009-11-04 |
| Last Update Date | 2025-10-15 |