| NPI | 1457085987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 5971256) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61487517) |
| Enumeration Date | 2022-07-11 |
| Last Update Date | 2025-06-24 |