| NPI | 1790379451 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA223530) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0007421) |
| Enumeration Date | 2021-02-23 |
| Last Update Date | 2025-03-11 |