| NPI | 1114035672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA10003791) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601007057) |
| Enumeration Date | 2006-08-26 |
| Last Update Date | 2025-06-17 |