| NPI | 1720706641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA61634146) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 63466) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-08-16 |
| Last Update Date | 2025-02-19 |