| NPI | 1467996785 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61160362) |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA61160362) | |
| Enumeration Date | 2016-12-05 |
| Last Update Date | 2024-01-09 |