| NPI | 1154731040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60575932) |
| Enumeration Date | 2014-05-01 |
| Last Update Date | 2018-06-25 |