| NPI | 1013045079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA60308571) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60308571) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2007-03-01 |
| Last Update Date | 2025-04-16 |