| NPI | 1134504103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA60999792) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OR PA172769) |
| Enumeration Date | 2015-07-20 |
| Last Update Date | 2025-03-06 |