| NPI | 1376772152 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA70007192) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5144) |
| Enumeration Date | 2009-07-14 |
| Last Update Date | 2025-09-26 |