| NPI | 1669024923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8327420-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61122689) |
| Enumeration Date | 2019-07-16 |
| Last Update Date | 2023-08-22 |