| NPI | 1235964644 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA61541888) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2024-09-05 |
| Last Update Date | 2024-11-13 |