| NPI | 1609481530 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61421619) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA60666) |
| Enumeration Date | 2020-09-08 |
| Last Update Date | 2023-09-24 |