| NPI | 1780087502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ID PA-1187) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OR PA173732) |
| Enumeration Date | 2014-10-07 |
| Last Update Date | 2026-05-18 |