| NPI | 1730581562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60745448) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9108201) |
| Enumeration Date | 2014-09-24 |
| Last Update Date | 2022-01-27 |