| NPI | 1104299601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60577634) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601013078) |
| Enumeration Date | 2015-11-05 |
| Last Update Date | 2025-05-20 |