| NPI | 1245632165 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61256932) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601007182) |
| Enumeration Date | 2014-09-23 |
| Last Update Date | 2024-03-21 |