| NPI | 1902275639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA219750) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA52868) |
| Enumeration Date | 2015-09-23 |
| Last Update Date | 2025-07-29 |