| NPI | 1992964563 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR P175245) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 5008334-1206) |
| Enumeration Date | 2008-06-08 |
| Last Update Date | 2026-05-01 |