| NPI | 1679035489 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61240820) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA200542) |
| Enumeration Date | 2019-04-01 |
| Last Update Date | 2023-09-13 |