| NPI | 1891276630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA224970) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 100201) |
| 363A00000X Physician Assistant (Licence: AZ 7819) | |
| Enumeration Date | 2018-08-28 |
| Last Update Date | 2025-07-31 |