| NPI | 1750806501 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA 61527130) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 54800) |
| Enumeration Date | 2017-08-12 |
| Last Update Date | 2024-10-29 |