| NPI | 1285148569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60858607) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 55592) |
| 363A00000X Physician Assistant (Licence: NV PA2190) | |
| Enumeration Date | 2017-11-25 |
| Last Update Date | 2022-11-03 |