| NPI | 1164581849 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA167) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA pa10004704) |
| Enumeration Date | 2006-12-08 |
| Last Update Date | 2021-09-01 |