| NPI | 1306519525 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA2170) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: WA PA61222585) | |
| Enumeration Date | 2021-07-26 |
| Last Update Date | 2021-12-22 |