| NPI | 1730593435 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60531551) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 2078) |
| Enumeration Date | 2014-06-20 |
| Last Update Date | 2025-05-29 |