| NPI | 1144605908 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60923665) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA1435) |
| Enumeration Date | 2015-07-22 |
| Last Update Date | 2022-11-07 |