| NPI | 1366172603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61662540) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 12762056-1206) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2022-06-10 |
| Last Update Date | 2025-05-06 |