| NPI | 1205303963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61354795) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 7280) |
| Enumeration Date | 2018-10-30 |
| Last Update Date | 2023-04-17 |