| NPI | 1659811644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9110336) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA 60741890) |
| Enumeration Date | 2017-02-24 |
| Last Update Date | 2017-10-13 |