| NPI | 1083394019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA61573662) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61573662) |
| Enumeration Date | 2023-07-24 |
| Last Update Date | 2025-11-24 |