| NPI | 1174096606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1715) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61522965) |
| Enumeration Date | 2019-01-08 |
| Last Update Date | 2024-03-28 |