| NPI | 1053984310 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61224843) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| Enumeration Date | 2021-07-22 |
| Last Update Date | 2022-06-27 |