| NPI | 1629363486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61240821) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 014701) |
| 363A00000X Physician Assistant (Licence: CA 21632) | |
| Enumeration Date | 2011-06-09 |
| Last Update Date | 2026-03-05 |