| NPI | 1366509507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: ID PA-904) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WA PA60143655) |
| Enumeration Date | 2007-01-03 |
| Last Update Date | 2022-03-14 |