| NPI | 1013693969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA61536054) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-06-26 |
| Last Update Date | 2024-05-28 |