| NPI | 1780179523 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA189018) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA0008030) |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA14661) | |
| Enumeration Date | 2018-06-25 |
| Last Update Date | 2026-01-24 |