| NPI | 1801456124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA197815) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA197815) |
| Enumeration Date | 2019-06-18 |
| Last Update Date | 2025-09-05 |