| NPI | 1740812791 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA MK8734875) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA061315) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA061315) | |
| Enumeration Date | 2020-02-07 |
| Last Update Date | 2024-04-23 |