| NPI | 1336219344 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 094487) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10000695) |
| Enumeration Date | 2006-11-08 |
| Last Update Date | 2019-06-11 |