| NPI | 1184200024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2021-0031) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61541645) |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA61541645) | |
| Enumeration Date | 2021-03-22 |
| Last Update Date | 2025-09-08 |