| NPI | 1215419957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61185297) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 098874) |
| Enumeration Date | 2018-08-29 |
| Last Update Date | 2022-11-07 |