| NPI | 1659913358 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA1063366) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA195761) |
| Enumeration Date | 2019-10-14 |
| Last Update Date | 2021-12-28 |