| NPI | 1770540122 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL 9105951) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OR PA217838) |
| 363A00000X Physician Assistant (Licence: OR PA217838) | |
| 363AM0700X Physician Assistant, Medical (Licence: AL PA2893) | |
| Enumeration Date | 2006-04-28 |
| Last Update Date | 2026-08-11 |