| NPI | 1720860232 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA223551) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-10-18 |
| Last Update Date | 2025-08-20 |