| NPI | 1518420314 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61067492) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA12784) |
| Enumeration Date | 2019-04-09 |
| Last Update Date | 2020-12-29 |