| NPI | 1154872786 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-86905) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60690704) |
| Enumeration Date | 2016-10-19 |
| Last Update Date | 2025-11-16 |