| NPI | 1245949759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61367686) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA.PA.61367686) |
| Enumeration Date | 2022-11-23 |
| Last Update Date | 2023-01-05 |