| NPI | 1093415929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61581291) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 6041) |
| Enumeration Date | 2023-03-08 |
| Last Update Date | 2024-09-30 |