| NPI | 1164934865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61073127) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA61073127) |
| Enumeration Date | 2017-11-02 |
| Last Update Date | 2024-08-01 |