| NPI | 1699103036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60696513) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA165108) |
| Enumeration Date | 2013-10-22 |
| Last Update Date | 2021-06-17 |