| NPI | 1487326765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61410321) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA8994) |
| Enumeration Date | 2021-10-04 |
| Last Update Date | 2025-08-19 |