| 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 |