| NPI | 1740287457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA151054) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60053080) |
| 363A00000X Physician Assistant (Licence: AZ 2861) | |
| Enumeration Date | 2005-07-07 |
| Last Update Date | 2026-06-01 |