| NPI | 1902427776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA207556) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA70030324) |
| Enumeration Date | 2020-05-02 |
| Last Update Date | 2025-09-29 |