| NPI | 1639194079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA10004622) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ID PA-1486) |
| Enumeration Date | 2006-07-13 |
| Last Update Date | 2021-05-20 |