| NPI | 1710130190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: SD 0692) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA164996) |
| Enumeration Date | 2008-10-29 |
| Last Update Date | 2025-09-10 |