| NPI | 1528632825 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA204375) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA.PA.61159625) |
| Enumeration Date | 2021-05-19 |
| Last Update Date | 2021-05-19 |