| NPI | 1265999056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 11111343-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60942025) |
| Enumeration Date | 2019-02-27 |
| Last Update Date | 2024-03-15 |