| NPI | 1669133641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA61499669) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2022-01-03 |
| Last Update Date | 2024-04-16 |