| NPI | 1063886935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61271444) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IL 085.005650) |
| Enumeration Date | 2015-11-16 |
| Last Update Date | 2025-04-03 |