| NPI | 1295106540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61120227) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 6242) |
| Enumeration Date | 2015-10-13 |
| Last Update Date | 2024-04-10 |