| NPI | 1285143933 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 5787) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA 60792494) |
| Enumeration Date | 2017-09-26 |
| Last Update Date | 2022-08-01 |