| NPI | 1174098065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA 61149560) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 025457) |
| Enumeration Date | 2018-10-08 |
| Last Update Date | 2022-08-01 |