| NPI | 1780563767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA227559) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: OR PA227559) |
| Enumeration Date | 2025-09-02 |
| Last Update Date | 2026-04-14 |