| NPI | 1548884588 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9118993) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61112965) |
| Enumeration Date | 2020-06-05 |
| Last Update Date | 2024-12-30 |