| NPI | 1215582861 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61000072) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 11362623-1206) |
| 363A00000X Physician Assistant (Licence: OR PA195884) | |
| Enumeration Date | 2019-08-08 |
| Last Update Date | 2023-03-03 |