| NPI | 1831717156 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA222378) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61128002) |
| Enumeration Date | 2020-07-13 |
| Last Update Date | 2026-05-15 |