| NPI | 1710346853 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61351500) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0004599) |
| Enumeration Date | 2016-02-17 |
| Last Update Date | 2023-01-05 |