| NPI | 1639549439 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60681685) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA2388) |
| Enumeration Date | 2015-10-06 |
| Last Update Date | 2025-02-07 |