| NPI | 1194243212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61155898) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA54864) |
| Enumeration Date | 2017-09-08 |
| Last Update Date | 2023-11-21 |