| NPI | 1356734966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA 60528565) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MT 147963) |
| Enumeration Date | 2015-03-07 |
| Last Update Date | 2025-04-01 |