NPI | 1720708886 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA226552) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2022-0085) |
Enumeration Date | 2022-08-30 |
Last Update Date | 2025-07-08 |