| 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 |