| NPI | 1457949448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61559558) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 2521) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-01-05 |
| Last Update Date | 2026-03-13 |