| NPI | 1689182529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61039111) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: OH 50.005416RX) |
| Enumeration Date | 2018-01-12 |
| Last Update Date | 2025-05-07 |