| NPI | 1447243597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 9581201) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10004160) |
| Enumeration Date | 2005-08-24 |
| Last Update Date | 2026-07-03 |