| NPI | 1265834659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60788623) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60788623) |
| Enumeration Date | 2014-09-17 |
| Last Update Date | 2023-12-06 |